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Sunday, September 06, 2009

Intentions Regarding Turning Off the Pacemaker of Reverend G

In the “Controversies” section of the Journal of the American Medical Association for February 23, 2000 there is a viewpoint as presented by Rhymes and colleagues titled “Withdrawing Very- Low Burden Interventions in Chronically Ill Patients”. The authors present a case about a severely demented elderly Reverend G who is “abusive, aggressive and assaultive” and “hallucinating”. His mental state and behavior cannot be controlled with any drug treatment. There is, on the other hand, an approach to management of this difficult patient.

Reverend G has a cardiac pacemaker “which the wife, with agreement from their children, has asked that the patient be given treatment to keep him comfortable and they asked that his pacemaker be turned off, on the assumption that the pacemaker may prevent an otherwise natural death.” The description of the case states that Reverend G had a living will written “before his dementia became severe” however it is not clear what the will stated except “he said that he did not want to commit suicide.” The authors provide arguments which support view that the wishes of the family is based on the rationale that turning off the pacemaker will end a “burdensome life” without representing physician-assisted suicide, euthanasia or “killing” the patient.

Ethicist Ed Pellegrino in a companion article in the same section of the Journal presents a moral algorithm for “Decisions to Withdraw Life Sustaining Treatment.” In it he finally argues that the reason for turning off the pacemaker should be if the intention was to remove a futile treatment but not if the intentions of the surrogates or medical attendants “were to hasten death…or to end a life which they unilaterally judged to be of ‘no quality’”

Which view would you hold? Is the pacemaker a futile treatment? Could one argue that the pacemaker is futile treatment, not because it can’t keep the heart beating normally, but because as a life-supportive mechanism it is failing to treat the patient’s dementia and what the family believes is simply maintaining a “burdensome life”? Can one call the pacemaker’s value as futile with regard to treating the mental disorder when it was inserted to treat the heart rhythm disturbance? And whose “burdensome life”? On the other hand could the decision by the family represent a loving concern for the patient who probably in recent times experienced not only the mental burdens but also most likely the physical burdens of physical restraints? What is your take on this scenario? ..Maurice.

16 Comments:

My friend said it was very traumatic emotionally for the family at her sister's bedside when she passed because the pacemaker had not been turned off. She died of cancer but her heart kept beating on. I don't know details but she said that it was very disturbing to the family.

There are two types of pacemakers,internal and external. Most have the implantable ones above the Ltnipple. Now,turning the pacer offmight not actually cause the patient to succumb,but rather causeundue suffering. Turning one off would not be considered suicide.

I believe that turning off the pacemaker would be a mistake in this case. As it has already been pointed out, stopping the pacemaker may not cause the patient's demise, but rather increase his suffering. Additionally, it would be worthwile exploring venues other than drug treatments to control the patient's mental state. The aforementionned symptoms can be CAUSED by the patient's current medication (worth investigating), an underlying medical condition (try diagnosing!). We would be kidding ourselves by saying that the pacemaker is a futile treatment, as it has no effect and was never intended to have an effect on mental status. I would suggest that the patient be intitutionalized, removed from all meds that are not critical in sustaining life and given a shot at re-diagnosing. Thus, the family will be "given a break" from the burden and the patient would have a second chance.

After several weeks of aggressive treatment with no improvement and because of many other severe health issues including diabetes, chronic foot ulcers, (previous amputations of toes), congestive heart failure with multiple previous heart operations(bypasses, stints, pacemaker etc.). Her doctors reported she was not a candidate for surgery to her colon (because she could not survive it) & offered her an option of "comfort care" (discontinuing all medical treatment to prolong her life) or continuing Intravenous feeding for another few weeks to see if she would get better. After 3 days while she was totally lucid, she decided and told her doctors that comfort care was what she wanted.

Unfortunately none of her doctors asked her if she would like her pacemaker turned off. Two days after starting on comfort care she was sleeping for 23 1/2 hours a day and could no longer speak.

Her living will did not address the pacemaker specifically, but did make it clear she did not want further medical treatment to prolong her life. I asked her nurses if her pacemaker should be turned off as part of he desired "comfort care", they asked the doctors and after questioning them further they had a technician from the Pacemaker company hook her up to a computer to audit the pacemaker's effect.

They determined the PM was adding 10 beats per minute to her own 50bpm and not keeping her alive.

After telling her cardiologist that she would not want the PM on if it prolonged her life by even an hour he agreed to turn it off. She died 2 1/2 days later in her sleep.

Doctors and patients should discuss if / when to turn off Pacemakers with regard to their end of life choices when they are prescribed and installed. These wishes need to be addressed in their Living wills and with their Health Care Surrogate / Health Care Power of Attorney.

When doctors are discussing "comfort Care" with their patient they should discuss and ask if the patient wants their Pacemaker turned off as part of their treatment.

AnonymousMy mother had a pacemaker placed several years ago after bypass surgery. Now she is on Hospice care in a nursing facility, bed-bound over a month, sleeping most of the time, not speaking. Her advance directives say she wants no artificial means to stand between her and dying. She would not want to be like she is now. She is 99% dependent on her pacemaker, according to her cardiologist. As health surrogate, I have requested pacemaker's deactivation. The company will come and hook it up for deactivation, but can not push the button to deactivate it bc she is dependent on it to live. The nursing center, by law, can have no part in deactivating it. She can not travel to the cardiologist's office. Any ideas?VB

VB, if this case is in the United States, the U.S. Supreme Court has ruled that a patient may refuse to continue life-supporting treatment. I am not sure what law would prevent the nursing facility from turning off the pacemaker at the patient's physicians order made at the patient's request. Most appropriately, the physician who prescribed or inserted the pacemaker is responsible to go to the patient and to turn it off at the request of the patient if no one else will do it, including the family. I would understand the emotional reason for the family not to press the button. ..Maurice.

Is it against the law in California to turn off a pacemaker? My father would like to have his turned off. His cardiologist told us today that it is against the law in California. My father is on hospice care...he does not wish to live longer than necessary.

He does not have a defibrillator. The Dr. said that by law a defibrillator can be shut off but not a pacemaker...and anyone who shut off a pacemaker could be prosecuted.

Is that correct? If so, do you know where I could find a copy of the law?

To my knowledge there are no laws which prevent a patient who has given consent in the past to have a cardiac pacemaker inserted from requesting and having the pacemaker turned off or removed. Every patient has the right to withdraw or withhold life supporting treatment. In the case of a cardiac pacemaker, turning it off will not necessarily immediately cause the death of the patient, however the patient may become more symptomatic because of a very slow heart beat, for example. If the patient is willing to have more, perhaps disabling symptoms, it is the patient's right to refuse having an active pacemaker. If the physician refuses to turn it off, the physician must refer the patient to a resource where the patient's request will be followed. To continue a treatment against the patient's wishes is not ethical nor is legal and could open the physician to legal prosecution. An exception would be, for example, an essential drug program to treat a communicable infection such as tuberculosis which could affect others if not appropriately treated. That certainly would not apply to your father's request.

Your father, by being under hospice care, means that he has a terminal illness where comfort and palliative care is the treatment. This treatment would not include a cardiac pacemaker if rejected by the patient.

Stating that the patient was sick with multiple issue; IH, mitral valve prolapse, valve disease, scars badly and has been told to go as long as possible without a third surgery to repair the artificial valve that has started to scar and seperate causing regurgitation and will only scar up again with little of the aortic trunk usable. How would it be viewed if the patient were to refuse having the battery changed when it came time to do so. Knowing full well that they are 100% dependant. It's not being turned off, but allowed to run out. PSH

I have a pacemaker, on my 2nd one now.I wish i did'nt get the 2nd one or they would just turn it off and let what ever happens happen. Im not mad or crazy I just feel different now about it all.Im not God. Well thanks JRayO

My 92yr mother-in-law has sustained at least 4 major strokes over 19mos leaving her with very little cognitive, (if any), paralyzed, unable to speak or feed herself, freq coughing with food or drink, cannot communicate any needs, is incontinent x2 and sleeps >22hrs/day. She is obviously uncomfortable every time we move her, and due to her skin being so thin, she constantly has wounds and bandages all over her body just from touching her. She has a history of congestive heart failure and A-fib; (among others just not cardiac related). She had her 1st pacemaker for 9yrs, and the current one for 7yrs. While on Hospice and slowly discontinuing all her routine meds, leaving only comfort care, I brought up the idea of turning off her pacemaker. Just found out that the last 2 checks in Jan & Oct of 2010 showed 100% dependency. She has been bedridden in our home this entire time. Can you give me some legal issues on deactivating her PM in this case and ethical to share with my husband since he knows it is the right thing to do, but is afraid of "killing her". Thank you DGL

I am not a lawyer but from what I understand about the current law and ethics, if the patient's legal surrogate, by expressing the substituted judgment of the patient to terminate unwanted continuation of pacemaker function at this stage of her life, then the pacemaker can and should be turned off. Substituted judgment means that the surrogate is aware of what the patient may have indicated in the past, in one way or another, which supports the decision by the surrogate to turn off the pacemaker. The decision cannot be made solely for the best interest of the surrogate or others but is made by what the patient would have wanted. The legal surrogate has that legal and ethical power to make that decision.

You can tell your husband that neither ethically nor legally will that substituted judgment represent "killing" the patient since the patient will be dying (if that occurs) because she will die from her underlying medical conditions, including heart disease, that required the various forms of life support. I hope this information helps. ..Maurice.

My wife was in icu she was talking normally sitting up i left because visiting hours are every 3 hours they called me in she had code the drs turned off her defibulator pacemaker so they could shock her i never gave the permission she had dialysis for 2 days they took her off and said a dr will be in the morning to put in bigger needles 2 hours later the bottom fell out they said she wasnt going to make and do i want them to keep her alive by shocking her i said no she has the defibulator she passed away the drs never turn her defibultor back on i did nit know that what did is it against the law.GS

GS, you appear to have had communication problems with your wife's doctors and what they did or did not do. It would be important for your understanding and comfort to sit down with the attending physician and have an explanation of what happened. ..Maurice.

I was relieved to find this thread on the blog. My father is 87, and has been in nursing facility for 18 months. At the time of entry, he was under Hospice care, but he has since been dropped/released by Hospice. He suffers from vascular dementia, and has reached a point where he does not recognize his family, even though my mother and one of three daughters visits him every day for four hours. He can do very little for himself, but is very uncooperative with the nurses and aides (for example, refusing to have his teeth brushed). My father's first pacemaker was deemed inadequate, and was replaced with a 3-lead pacemaker and defibrillator model. However, he has continued to suffer subsequent vascular "events" which have resulted in a dramatic loss in cognitive function. The defibrillator was turned off by Dad's cardiologist before he entered the nursing facility, and the doctor said he would come to the facility to turn off the pacemaker "when the time comes". We've never known what that phrase meant...when Dad actually dies, or when we feel the time has come? It is good to know that it IS legal to have a pacemaker "turned off", and I hope we can start looking in to the possibility soon. S.S.

S.S., I assume the doctor intended to turn off the pacemaker at the time the patient's surrogate (who speaks for the patient's desires as to what the surrogate understands would be the patient's desires based on previous communications) makes that request. Of course, turning off the pacemaker does not cause the immediate death of the patient if the heart continues to beat normally on its own. Turning off a pacemaker after death, is, of course, of no significance for the deceased, is a issue I never encountered, in my own experience, and is something I should research. ..Maurice.

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